[This is a work in progress and mostly unedited. It will be completed soon, but feel free to start reading.]
It’s terrible, but true: some patients are the jagged little rocks scattered about your otherwise peaceful Zen garden. They never leave (either your practice or the actual appointment), have bizarre needs, and always manage to turn your feng shui into feng fray. When I was an intern, the
martyr resident who normally treated Julie’s family called in sick, necessitating a rescheduling of the day’s appointments. Three of us had an available opening, but the other residents had a slightly panicked look on their faces.
“Hey, uh, Ren! You need numbers for graduation. You could get both kids in one visit!” grinned Dr. G. with a snap. “Two in one.” His smile was suspicious … everyone knows interns are incapable of smiling until the next wave of indentured servants start in July. Besides, he kinda looked like this:
“Uh huh. You’re an intern too, why don’t you want the numbers?”
“Pfft. Are you kidding? I’ve got tons of numbers. I was just being nice.” He turned to walk away muttering something along the lines of “harbinger of doom,” which naturally led a group of mature, budding physicians to burst into an infantile battle of “you-owe-mes.” Our nurses were not amused.
Our Attending intervened with the perfect solution of Rock-Paper-Scissors, and thereafter I remained the physician for Julie and her two sons.
They didn’t come in much, but when they did, I had thirty minutes to address problems with both boys. Rather than thirty, however, these clinic appointments often stretched to an hour, putting the rest of my day off an already tight schedule. The boys, Andy and Mark, both possessed frames made for quarterbacking, whereas Julie was extremely thin and looked like she either lacked enough money to buy groceries, was anorexic, or was doing drugs (cocaine can produce a similar wasted-away effect, and I often thought this was one of her demons). Her children were polite but silent as I listened to a high-strung, poorly educated, suspected drug-abusing mother tell me about how they were defiant, violent, destructive, and often ditched school. They were early teens, maybe 14 and 16 years old. There were entire days Julie had no idea where her boys were until they made their way home after dark.
“Andy? Mark?” I’d ask gently, knowing very well there were two sides to this story. “What do you think about what your mother has to say?” Frankly, I always trusted the boys more than their mother, who was either high when she came in, or manic from untreated bipolar disorder. I was never sure what she wanted me to do. She thought there was some kind of magic pill I could provide to “bring the boys in line.”
In response, the boys would shrug and tell me stories about how school “just didn’t work for them.” How they “couldn’t learn anyway,” and had “worthless teachers.” While they sat there, they would fidget. Constantly. Tapping shoes. Grinding teeth. Getting up to pick things up in the room or play with the otoscope. Shake their knee. They just couldn’t stop, and their mother was no better. She was practically vibrating in place, opening and closing her purse, rubbing her arms (another drug hint, usually associated with meth), and shifting in her seat. I could never get more than three sentences in before she was interrupting me again. By the time they left my office with encouragement to visit their social worker to be set up for further psych testing, I was exhausted.
Several months after one family visit, the mother came to see me alone. I winced when I saw her name on my schedule, but I entered with a smile and asked how the boys were doing.
“Oh, same as always.”
I nodded, as I noticed she looked less gaunt than normal.
“Did you ever get them into the case worker?” I prompted, already knowing the answer.
“Ah, well, I meant to, but I just keep forgetting. You know how it is. But, listen, doctor, I won’t take up your time. I just needed to know how far along I am.”
I paused. “Along?”
“I’m pregnant. I need to see if I’m early enough to get an abortion. I just can’t have another kid, yet alone one like those boys.”
I’ll save the description of my inner turmoil during this patient case, lest I launch into a ten-page diatribe about responsible reproduction. But to summarize, I followed through with my medical obligations the best I could, and provided all the information to my patient for her to make a safe choice. Julie was relieved she was under twenty weeks and was scheduled for an abortion the next day. It was her eighth abortion, and twelfth pregnancy.
This case may be an odd one to use for an ADHD topic, but it has some excellent points that fit into the larger cultural debate about ADHD and the validity of the diagnosis. Certainly, Julie and her family could be the case study of countless social issues including poverty, lack of education, drug abuse, teenage violence, and reproductive rights. But what I wonder is, how much of what I saw was the result of nature, and how much was nurture?
So, let me first summarize the debate surrounding ADHD: Is it a real diagnosis, or is it a made-up shenanigan by pharmaceutical companies which doctors and teachers have bought into? This is a question of vital concern to those who are confronting ADHD in their lives, either because a teacher has suggested it to a parent, or because a child is having learning difficulties, or because an adult is struggling to manage his or her life. There is a perception among social and professional circles that ADHD is a misleading title for what the medical profession calls PPP: Piss Poor Parenting. But is it really?
Naturally, I’m writing a blog about ADHD, so my readers can assume I believe in the medical validity of the diagnosis. I am also a physician trained to recognize it (although its treatment I deferred to specialists). I’m a clear advocate for the diagnosis, but I will also tell you why and list the points used against it. The reader can decide for himself. Julie’s family will provide a case study for us to consider throughout this discussion.
ADHD is Still Debated Among Medical Professionals
This is a common assertion made by anti-ADHD advocates. But is it true? From personal experience, there was never a time in my medical career, either pre-med, medical school, or residency, when the diagnosis was up for debate. It was presented as fact, with copious amounts of evidence regarding the diagnostic method, the associated factors (e.g. an increased incidence in males), and clearly positive results after patients started stimulants.